The treatment of immature heterotopic ossification in spinal cord injury with combination surgery, radiation therapy and NSAID

Abstract

Heterotopic ossi®cation (HO) is a frequent complication associated with spinal cord injury. Management of HO consists of a combination of range-of-motion, diphosphonates, nonsteroidal antiin¯ammatory agents, radiation therapy, and in some cases, surgical resection. The appropriate timing of surgical resection has traditionally been based on maturity of the HO. The case presented is that of a 33-year-old male with T8 complete paraplegia who developed HO about the left hip resulting in impaired sitting. The patient underwent successful surgical wedge resection of the HO despite apparent immaturity of the HO. A comprehensive review of the literature is presented which suggests that early resection of immature HO may not be predictive of a higher recurrence rate.

Prevention of heterotopic ossification after spinal cord injury with indomethacin

“…Di erent preventive protocols have been used, such as etidronate, 24,25 NSAIDs in combination with etidronate and radiation therapy, 26 NSAIDs alone 27,28 or with etidronate. 29 Garland et al used etidronate in nine patients after surgical resection of HO and were not able to determine its bene®ts against recurrence of HO.…”

Neurogenic heterotopic ossification in spinal cord injury

“…There was also no correlation between NHO recurrence and the time post SCI or NHO onset. 49,174,177 Recently McAuli e et al 170 and Freebourn 177 reported three patients that had successfully undergone early resection of NHO, that is within 7 ± 11 months post SCI. Earlier surgery may be warranted to prevent ®brous ankylosis, muscle contractures, and severe disuse osteoporosis to decrease the intra-operative fracturation rate.…”

Osteonecrosis after treatment for heterotopic ossification in spinal cord injury with the combination of surgery, irradiation, and an NSAID

“…9 ± 11,24,31 While Stover did not ®nd any correlation between the extent of recurrence and length of onset of HO to surgery, 29 Freebourn stated that early resection of immature HO may not be predictive of a higher recurrence rate. 32 Because HO resection is associated with poor outcome mainly due to a high recurrence rate, di erent prophylactic methods have been developed to reduce the recurrence rate. Both irradiation and indomethacin seem to be e ective in preventing HO occurrence after total hip replacement.…”

“…Irradiation may disrupt the di erentiation process of pluripotential mesenchymal cells into osteoblasts. 32,34 It may also serve to decrease pain perception associated with the tissue in¯ammatory reaction around the side of HO, or it may be involved in ablation of pain receptors. 34 Post-operative irradiation has been reported to decrease the recurrence of HO after surgical resection of HO in SCI, but no controlled studies are available.…”

“…39 Anti-in¯ammatory drugs inhibit the formation of prostaglandins and related substances which trigger the local bone remodelling, thereby reducing the formative and resorptive phases of bone remodelling. 27,28,32 Both indomethacin and radiation therapy could exert their prophylactic e ects by preventing the di erentiation of the pluripotential mesenchymal cells into osteogenic cells.…”